People's pharmacy: How to avoid disaster at the drugstore

Pharmacists remain among the more trusted professionals in America, just behind nurses and ahead of doctors, engineers, dentists and police officers. But even pharmacists make mistakes.

We recently received a letter from a reader: "Yesterday, I discovered that when my diabetes prescription was refilled, the druggist made a mistake and gave me something else. I didn't catch it at first because there was a note on the bottle saying that while the shape was different, it was the same prescription.

"My blood sugar numbers crept up, and I began to think there was a problem. I scrutinized the tablet, and instead of saying 1.5, it read 1.25. I went to the drugstore, and they confirmed that not only was it the wrong dosage, it was the wrong medication.

"Always check refills to make sure they are what they are supposed to be. Some pills can cause harm and even death to those who are not supposed to take them. I have no idea what drug I was given, but I'm glad that it caused me no problems except for uncontrolled blood sugar for several days."

Another reader averted a potentially serious problem by checking before she left the pharmacy: "My 11-year-old daughter takes Intuniv (guanfacine) for ADHD. When I picked up her prescription, I was given Invega (paliperidone) instead. This is an atypical antipsychotic used for the treatment of schizophrenia.

"Luckily I noticed before I even left the pharmacy. When I asked the tech, she said someone must have made a mistake entering it into the computer. She did it over and gave me the correct medicine.

"I don't understand why they didn't check her history and see that she takes Intuniv. I was told there is a many-step process before the prescription is released. So how did I get handed this incorrect medicine? Even more important, what could it have done to my 75-pound daughter?"

Sometimes a mistake leads to tragedy. A pharmacist in Illinois dispensed the diabetes medicine glipizide instead of the gout drug allopurinol. The patient did not notice the error, and his blood sugar went dangerously low. He suffered serious consequences, including a stroke, and ultimately died. The family sued the drug chain, and a jury awarded $31 million in damages (Drug Topics, Nov. 6, 2006).

You can learn more about the many things that might go wrong at the drugstore in "Pharmacy Exposed" by Dennis Miller, a registered pharmacist. We also provide a list of the top 10 pharmacist errors and information on how to protect yourself in our book "Top Screwups Doctors Make and How to Avoid Them."

Here are some safety tactics to employ the next time you pick up a prescription:

- Keep a copy of your prescription, and check the pill bottle you are given to make sure it agrees. Do this before you walk away from the cash register.

- Ask your pharmacist how to take the medicine. Find out if it matters whether you take it with food or on an empty stomach, and whether there are any beverages such as grapefruit juice or coffee that are incompatible.

- Review with the pharmacist all other drugs you take, including OTCs. Make sure you are not setting yourself up for a dangerous interaction.

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Joe Graedon is a pharmacologist. Teresa Graedon holds a doctorate in medical anthropology and is a
nutrition expert.